Older ED Patients Face Barriers to Recommended Outpatient Care

By Stacey Kusterbeck

“Follow up with your primary care doctor in the next three to five days.” It is a very common instruction given by ED providers at discharge — but often, an unrealistic one.

Cameron Gettel, MD, MHS, was seeing an increasing amount of older adults presenting to the ED. Some stated that they came to the ED specifically because they could not get in to see their primary care physician. Gettel wondered if the same was true regarding primary care access after the ED visit.

“I often tell older adults to ‘Follow up in a few days.’ I wanted to quantify how possible that actually was,” says Gettel, an assistant professor in the Department of Emergency Medicine at Yale School of Medicine.

Gettel and colleagues conducted a study to find out the proportion of older adults (defined as 65 years of age or older) discharged from the ED who were able to access primary care follow-up within four days. “There are numerous patient safety implications for older adults at the time of discharge,” notes Gettel. Patients are at risk for avoidable ED revisits or hospitalizations, loss of mobility and function, and mortality. The researchers analyzed data from 223 older adults to determine if patients had seen a primary care physician within four days after the initial ED visit.¹ Only 26% of patients reported having obtained follow-up within four days.

For ED providers, this concerning finding points to the need to take a few minutes to carefully consider the need for follow-up on an individual basis. Some patients might not really need to “follow up in a few days.” “It’s our job to discuss that with the patient, rather than making blanket statements about follow-up or filling out discharge instructions with templated material that older adults may have difficulty deciphering,” says Gettel.

Gettel notes that it is important for ED providers to be clear on these specifics, both verbally with the patient and in writing in the ED medical record:

• with whom the patient should follow up;

• the contact information of that physician’s office,

• how soon the follow-up needs to happen.

Ideally, the patient’s primary care physician would see that the patient was in the ED via the EMR and would reach out to the patient to schedule the appointment. “But the patient should also call the office themselves the following business day to avoid letting the follow-up ball drop,” Gettel emphasizes.

Lack of primary care access post-ED discharge “is a major problem,” according to Robert W. Derlet, MD, a professor emeritus of emergency medicine at the University of California, Davis. Many people wait a month or longer just to see their primary care physicians. A new patient appointment can take months to schedule. Thus, patients either return to the ED or go to urgent care if they need additional care. In some cases, a patient’s condition is stable at the time of ED discharge but becomes unstable at some point after the patient leaves the ED. “This is a new area of litigation against hospital systems. They know that it is hard to access their clinics, yet send potentially unstable people out. While this does not technically violate EMTALA, it is wrong,” says Derlet.

When discharging a patient from the ED, clinicians should consider risks pertaining to specific patient populations, says Alissa R. Gorelick-Wisniewski, DO, an emergency medicine attending physician at Endeavor Health and OSF HealthCare. “Higher-risk populations, such as pediatric patients, medically complex patients, and the elderly, will benefit from closed loop communication amongst clinicians regarding their ED care and follow-up,” adds Gorelick-Wisniewski.

Ideally, clinicians should speak with the primary care doctor or on-call specialist directly while the patient is in the ED to ensure close follow-up is plausible, says Gorelick-Wisniewski. That way, the ED provider can “close the loop” and tell the patient: “You have an appointment scheduled with the urology clinic on Thursday at 10 a.m.” It is not always possible. “It can be difficult to make contact with clinicians who are not formally on call or not able to answer back promptly,” acknowledges Gorelick-Wisniewski. “However, attempting to make this connection is important for our patients.” ED providers also could leave a message with the paging service to contact the patient directly in the morning or send a message through secure chat forums.

ED providers cannot anticipate all the obstacles that may preclude patients from obtaining prompt ED follow-up. “However, we should take into account the more common and avoidable issues,” asserts Gorelick-Wisniewski. In small rural communities, specialists may not be accessible on a daily or even weekly basis. ED providers must take that reality into consideration before determining if a patient can be safely discharged. In some cases, it is medically reasonable to discharge an elderly patient with an ED diagnosis of a kidney stone. However, the decision might depend on access to a local urologist — whether one is available at all, and if so, when the patient can be seen.

Inability to get a timely appointment is not the only obstacle. “The reality of emergency departments in this day and age is that we are a safety net for many communities, especially at-risk populations,” says Gorelick-Wisniewski. Not all older patients can obtain medications prescribed at discharge. Not all have transportation to doctors’ offices. ED providers might find solutions by reaching out to the patient’s support system. “As long as the patient gives consent for us to speak with their family or friend, and we can verify the person we are reaching out to, this communication can help to ensure that quality post-ED care is achieved,” says Gorelick-Wisniewski.

It is in the patient’s best interest for emergency medicine providers to consider their medical and social needs during the ED visit. The same holds true for follow-up care. “This can be a lofty task, especially in EDs that are under-resourced. Nonetheless, maximizing communication with our patients, their families, and their medical teams will improve patient care,” says Gorelick-Wisniewski.

REFERENCE

1. Gettel CJ, Hartzheim J, Chera T, et al. “Follow-up in a few days”: Limitations to primary care access among older adults following emergency department discharge. J Am Geriatr Soc 2024; Feb 2. doi: 10.1111/jgs.18791. [Online ahead of print].